Socialstyrelsen menar att primärvården står inför en utmaning att tillgodose tillgänglig psykologisk behandling till ett växande behov. Ett möjligt tillvägagångssätt skulle kunna vara Integrerad beteendehälsa som eftersträvar att kunna erbjuda korta psykologiska interventioner med hög tillgänglighet. Syftet med föreliggande studie var att jämföra två varianter av Integrerad beteendehälsa; ett sedvanligt upplägg med Brief Interventions och ett upplägg med utökad bedömning och möjligheten till vägledd självhjälp för ett specifikt problem. Det här med avseende på generella symtom och symtom specifika för just det problem som patienter erhållit självhjälp för, alternativt bedömts skulle ha passat för självhjälp avseende ett specifikt problem. Resultaten visade att den generella symtomnivån förbättrades för gruppen som helhet, samt inom respektive grupp. Den problemspecifika symtomnivån sjönk för både patienter som erhållit vägledd självhjälp och för patienter som erhållit Brief Interventions men vars problemprofil visat att de hade passat för en specifik självhjälpsmanual. Någon signifikant skillnad i symtomförändring, oavsett generell eller problemspecifik, kunde inte hittas. I diskussionen problematiseras bland annat den interna validiteten och den naturalistiska miljön lyfts som en styrka. / The national board of health and wellfare are stating that primary care faces a major challenge in providing available psychological treatment to an increasing need. One possible approach is Integrated Behavioral Health, which strives towards offering brief psychological interventions with great access. The purpose of the following study was to compare two different methods of Integrated Behavioral Health; an ordinary set up with Brief Interventions and one set up with extended assesment and the possibility of guided self-help treatment for a particular problem. This regarding general as well as specific symptoms for the particular problem the patient has received guided self-help for, or considered to have been suited for. The results showed that the general level of symptoms improved for all patients, merged into one group, and within the respective group. The level of the problem-specific symptom decreased for patients who received guided self-help and for patients who received Brief Interventions, but whose problem profile showed that they had fit for a specific self-help manual. No significant difference in symptom change, regardless of general or problem- specific, could be found. In the discussion, the internal validity is discussed, and the naturalistic environment is described as a strength.

Primärvårdens uppdrag innefattar behandling av psykisk ohälsa och för närvarande överstiger behandlingsbehovet vårdnivåns resurser. Integrerad beteendehälsa (IBH) är en organisationsmodell för primärvård som tidseffektivt tillgängliggör psykologisk behandling. Föreliggande pilotstudie ägde rum under perioden januari till april 2019 på vårdcentralen Centrum, som arbetade enligt modellen för IBH. Syftet för studien var att utvärdera effekterna av behandling med Brief Interventions (BI) respektive vägledd självhjälp avseende patienternas vardagliga funktionsnivå, livskvalitet och symtom. Mätningar genomfördes innan behandling påbörjades, efter fyra veckor samt efter åtta veckor. Vidare undersöktes processfaktorer, så som hur stor andel av patienterna som skulle kunna tillgodogöra sig behandling med självhjälp, samt huruvida införande av en sådan behandling skulle kunna vara motiverad i primärvårdsmiljö utifrån tidseffektivitetsperspektiv. Totalt randomiserades 41 patienter mellan behandling med BI respektive en utökad bedömning följt av behandling med vägledd självhjälp. De patienter som vid den utökade bedömningen inte befanns lämpliga för vägledd självhjälp fick behandling med BI. Sammantaget fullföljde 29 patienter behandling inom ramen för studien. Resultaten visade att både BI och självhjälp förbättrade patienternas vardagliga funktionsnivå, livskvalitet och symtomnivå, samt att det fanns få skillnader i behandlingsutfall mellan grupperna. Tidsåtgången för personalen var större för behandling med självhjälp jämfört med BI. Vidare forskning behövs för att utvärdera psykologisk behandling anpassad till primärvården. / A commitment of primary care is mental health treatment. At present the need for treatment exceeds accessible resources. Primary Care Behavioral Health (PCBH) is a model of organization of primary care with the aim to make access to mental treatment from a time-efficiency perspective. The present study was conducted between January and April 2019 at Vårdcentralen Centrum, a primary care unit organized in accordance with PCBH. The aim of the present study was to evaluate the effects of treatment with Brief Interventions (BI) and guided self-help regarding daily functioning, quality of life and aggregate level of symptoms. Self-assessments were filled out by the patients before treatment, at FU4 and at FU8. Furthermore, proportion of patients suitable for self-help treatment was examined, and whether introduction of such a treatment might be justified in the context of primary care on basis of time effectiveness approach. In overall, 41 patients were randomized to two conditions: BI treatment and, respectively, extended assessment with subsequent self-help treatment. Participants, not found suitable for self-help at the extended assessment, got treatment with BI. Within the study, 29 patients went through treatment. The results showed that groups treated with BI and self-help had improved significantly between before treatment and FU8 regarding daily functioning, quality of life and level of symptoms. There were in general little differences in improvement between the two groups. Furthermore, timescale for the group that got extended assessment and subsequent self-help treatment, was significantly larger than timescale for the group that got BI treatment. For future research, evaluation of short-term forms of mental treatment in primary care ought to be relevant.

Introdução: O Projeto Terapêutico Singular (PTS) é um conjunto de condutas e propostas terapêuticas que orientam o trabalho direcionado a um sujeito singular e coletivo, que resulta da discussão coletiva interdisciplinar de profissionais de determinado serviço de saúde e se consolida em cenário histórico e de Políticas Públicas, orientado em âmbito nacional pelo Sistema Único de Saúde. Objetivos: Realizar uma Revisão Integrativa da Literatura sobre o tema PTS. Identificar, na literatura, se a construção do PTS no campo psicossocial atende a seus pressupostos teóricos e conceituais e, indicar a re-organização do trabalho com vistas à construção compartilhada do PTS junto ao usuário, no campo psicossocial, a partir das normativas e diretrizes do Ministério da Saúde, na vigência da RAPS. Método: Trata-se de um estudo de Revisão Integrativa da Literatura. Utilizou-se dois descritores de assuntos combinados: Assistência Integral à Saúde e Serviços de Saúde Mental. A palavra-chave Projeto Terapêutico Singular foi utilizada em algumas bases de dados com o intuito de refinar buscas que se mostraram muito amplas. Os dados foram coletados no Banco de Teses e Dissertações da CAPES e da USP, Biblioteca Virtual em Saúde e, nas bases de dados, Cinahl, Pubmed e Web of Science. O período de publicação das referências localizadas não foi limitado. Resultados: Foram selecionados 14 estudos, produzidos no período de 1997 a 2014, sendo que 13 deles realizados em âmbito nacional e, apenas um foi produzido em âmbito internacional. Para análise dos estudos, buscou-se a categorização dos achados em cinco grupos: 1) conceitos e bases teóricas do campo psicossocial e da reabilitação como cidadania; 2) estrutura, forma e o como-fazer dos projetos terapêuticos singulares; 3) vantagens do emprego do projeto terapêutico singular nas práticas assistenciais; 4) os desafios, obstáculos e dificuldades nos quais o PTS esbarra; 5) as propostas para superação dos desafios relacionados ao PTS. Conclusões: A presente revisão integrativa valeu-se da combinação do uso de descritores de assunto e palavra-chave, o que permitiu a recuperação de maior número de estudos, pertinentes ao objetivo estabelecido. O PTS é ferramenta potente de cuidado, porém enfrenta muitos desafios para seu desenvolvimento o que pode restringir suas potencialidades. Foi recomendado que estudos futuros proponham um registro norteador de ações, que corresponda aos saberes teóricos e conceituais do campo psicossocial e da reabilitação como cidadania, de modo a contribuir com a elaboração do PTS. Esse norteador de ações deve apontar para a possibilidade de guiar a construção coletiva do PTS para atingir de forma efetiva a reabilitação psicossocial, a qualidade de vida, a dignidade, o poder de troca de mercadorias, de apoio social e familiar e de direito de pertencimento, ou seja, do verdadeiro direito à cidadania e a vida. / Introduction: The Singular Therapeutic Project (known as PTS in Brazil) is an arrangement of therapeuct actions that is due to guide the work process directed towards a singular person or a collective subjects, that results in an interdisciplinary collective discussion of employees of health services and has its bases in a historical setting and Public Policies, oriented at the national level by the National Health System. Objective: Identify if the development of the PTS in the psychosocial field meets its theoretical and conceptual assumptions, as well as propose the rearrangement of the work processes, aiming the shared development of the PTS with the user of the health services, in the psychosocial field, through the regulations and guidelines of the Ministry of Health, in the presence of the governement program Attention Networks to Psychosocial Health (known as RAPS). Method: Its an Integrative Literature Review. Were combined in this review two index-terms: Comprehensive Health Care and Mental Health Services. The keyword Therapeutic Project was used in same databases in order to refine searches that were very broad. Data were collected at the Bank of Theses and Dissertations of CAPES and USP, Virtual Health Library and, in the databases, Cinahl, Pubmed and Web of Science. The period of publication of localized references was not limited. Results: A total of fourteen (14) studies, producted from 1997 to 2014. Thirteen (13) of them were performed at the national level and only one of them was produced internationally. For analysis of the studies, we sought to categorize the findings into five groups: 1) concepts and theoretical bases of the psychosocial field and the rehabilitation as citizenship; 2) structure, shape and the how-to of the PTS; 3) advantages of using the PTS in the health care practices; 4) the challenges, obstacles and difficulties that the PTS faces; 5) proposals for overcoming the challenges related to PTS. Conclusion: This Integrative Review drew on the combination of the index-terms and keyword, which allowed the recovery of the greatest number of relevant studies to the proposed goal. The PTS is a powerful tool care, but it faces many challenges to its development which may restrict its potentialities. It is recommended that future studies could propose a registration that guides actions, which corresponds to the theoretical and conceptual knowledge of the psychosocial field and the rehabilitation as citizenship, in order to contribute to the development of the PTS. This guide for the actions should point the possibility of guiding the collective construction of the PTS to achieve effectively the psychosocial rehabilitation, the quality of life, the dignity, the social exchanges, the labor, the social and family support and the right of belonging, in other words, the true right to citizenship and life.

Introdução: O interesse pelo tema investigado surgiu durante o curso de Graduação em Enfermagem, ao vivenciar junto aos colegas graduandos situações de morte e morrer. Em uma dada ocasião, já atuando como profissional, fui questionada por um membro da equipe de enfermagem sobre a real necessidade da manutenção de alguns procedimentos como, curativos e exames laboratoriais, para pacientes em cuidados paliativos, em fase final de vida. Impulsionada pelos acontecimentos descritos anteriormente e pela vontade de aprofundar meus conhecimentos sobre cuidados paliativos e compreender um pouco mais sobre aspectos relacionados a esse tema na enfermagem, ingressei no Programa de Pós- Graduação em Enfermagem da Escola de Enfermagem da Universidade de São Paulo. Objetivos: Revelar as concepções sobre Cuidados Paliativos (CP) das enfermeiras da Estratégia Saúde da Família (ESF), Caracterizar perfil sociodemográfico das enfermeiras da ESF, Identificar os significados atribuídos pelas enfermeiras da ESF aos CP, Conhecer as percepções dos enfermeiros sobre as necessidades de CP, Revelar as percepções das enfermeiras sobre a formação necessária para a prestação de CP na ESF. Método: Estudo descritivo, de caráter exploratório, com abordagem qualitativa. Resultados: Participaram do estudo doze enfermeiros, dos quais onze eram do sexo feminino, com idades entre 27 e 64 anos, com no mínimo 02 meses e no máximo 42 anos de formação em Enfermagem, com no mínimo uma e no máximo seis pós-graduações Lato Sensu. As mais citadas foram: Estratégia Saúde da Família, Saúde Pública e Administração Hospitalar. Para responder aos objetivos, realizamos o agrupamento dos dados de acordo com as semelhanças observadas nas respostas dos entrevistados para posterior formulação de temas e obtivemos como tais: Concepções sobre Cuidados Paliativos, Necessidades do paciente em Cuidados Paliativos e Formação do enfermeiro em CP. Conclusão: Os CP vieram para ocupar uma lacuna importantíssima, que precisava ser preenchida com certa urgência, proporcionando assim um cuidado mais efetivo para o paciente portador de doenças sem possibilidade de cura. Cuidado esse primordial para aplacar o sofrimento que nascia da falta de dignidade e impotência de pacientes e famílias diante de tamanha fúria e agressividade observadas muitas vezes por esses grupos; não por falta de empenho da equipe, mas sim em alguns casos, por falta de preparo efetivo para lidar com essas situações. Sendo assim, verificou-se a necessidade da capacitação e orientação para manusear e utilizar instrumentos que direcionem a prática da enfermeira da AB que lida com paciente em CP e também do aprimoramento técnico científico direcionado especificamente para esse aspecto do processo de morte e morrer, pois, nesse momento tão delicado da vida do paciente e de seus familiares a equipe precisa estar preparada para acolher e desenvolver o melhor atendimento em saúde possível, pautado no conhecimento e também no cuidado humanizado. São Camilo de Lelis é autor da frase: Mais coração nas mãos, ou seja, humanização e aprimoramento para tratar daquele que precisa de auxílio. / Introduction: The interest in the research theme emerged during the course of undergraduate nursing, to live together with fellow undergrads situations of death and dying. On a given occasion, already working as a professional, I was questioned by a member of the nursing staff on the real need to maintain some procedures as dressings and laboratory tests for patients in palliative care, end of life phase. Driven by the above-described events and the desire to deepen my knowledge about palliative care and understand a little more about aspects related to this topic in nursing, I joined the Graduate Program in Nursing at the University of São Paulo School of Nursing. Objectives: Develop the concepts of Palliative Care (PC) of the nurses of the Family Health Strategy (FHS), characterize sociodemographic profile of the FHS nurses identify the meanings attributed by the nurses of the ESF to the CP, know the perceptions of nurses about the needs of CP, reveal the perceptions of nurses about the training required for the provision of CP in the FHS. Method: A descriptive study, exploratory, with qualitative approach. Results: The study included twelve nurses, eleven of whom were female, aged between 27 and 64 years with at least 02 months and no more than 42 years of training in nursing, with at least one and at most six postgraduates Lato sensu. The most cited were: the Family Health Strategy, Public Health and Hospital Administration. To meet the goals, perform the grouping of data according to the similarities observed in the respondents\' answers to subsequent formulation of themes and obtained as such: Conceptions about palliative care, patient needs in palliative care and nursing training in CP. Conclusion: CP came to occupy a very important gap that needed to be filled with some urgency, thus providing a more effective care for patients with multiple diseases without possibility of cure. Watch this vital to assuage the suffering born of unworthiness and helplessness of patients and families faced with such fury and aggression observed many times by these groups; not for lack of team commitment, but in some cases, lack of effective preparation to deal with these situations. Thus, there was the need for training and guidance to handle and use tools that address the practice of AB nurse who deals with patients in CP and also the scientific technical improvement specifically directed to that aspect of the process of death and dying as at that time so gentle the life of patients and their families the team must be prepared to accept and develop the best possible care in health, based on knowledge and also in humanized care. St. Camillus de Lellis is the author of the phrase: \"More heart in hands\", ie, humanization and improvement to treat one who needs help.

Esta tese discute a organização tecnológica do cuidado em saúde à luz das políticas de saúde bucal. Metodologicamente estruturou-se em um histórico das políticas de saúde bucal no Brasil desde a década de 1950 aos dias atuais, na vigência da Política Nacional de Saúde Bucal (PNSB, 2004). A abordagem das políticas procedeu-se sob teoria de M. Foucault na obra Arqueologia do Saber (1997). O estudo buscou apreender qual saber operante, (Mendes Gonçalves 1979, 1994) tem organizado a prática neste campo. Utilizou-se de revisão de documentos normativos do SUS e de publicações do período de 2000 a 2012. Procurou-se desvelar, a partir da organização tecnológica (categoria de análise) como a atual política aborda as necessidades de saúde da população e quais ferramentas/instrumentos/tecnologias são oferecidas para o cuidado em saúde bucal. O SUS busca tem buscado a mudança de modelos de atenção e de organização do trabalho que transformem a prática de assistência odontológica (ineficaz, baixa cobertura, monopolista, baixa resolubilidade, mal distribuída geográfica e socialmente), por modelos voltados à promoção da saúde. No entanto, de acordo com levantamento de artigos sobre a condução da atual PNSB no cotidiano dos serviços públicos de saúde, destacou um modus operandi ainda calcado na pragmática odontologia, plena de conflitos e contradições. A abordagem de conceitos como promoção da saúde, integralidade e cuidado em saúde trouxeram a este estudo uma luminosidade, uma clareza ao olhar a prática em saúde bucal. O histórico das Políticas em Saúde Bucal foi fundamental para compor a análise da organização tecnológica e os processos de trabalho, pois realçaram que o fio condutor das práticas tem sido realizado, de forma linear, por abordagens ainda muito centradas no conhecimento biológico do adoecimento. Para que de fato um novo modelo como propõe a PNSB transforme a prática em saúde bucal com novos arranjos tecnológicos no processo de trabalho, outras formas de vínculo e comprometimento devem ser almejadas. É necessário melhorar a formação e a prática profissional com a adição de novos saberes que, por sua vez, irão exigir novos padrões cognitivos e culturais. Há que se qualificar a escuta sobre os padecimentos do paciente, ir além do diagnóstico de sinais e sintomas, apreender as subjetividades produzidas na condição do adoecimento. Talvez estes processos consigam legitimar a saúde bucal como um dos componentes da saúde em uma expressão ampliada: a da qualidade de vida. / This thesis discusses the technological organization of health care in light of the dental health policies. Methodologically structured in a history of oral health policies in Brazil since the 1950s to today, in the presence of the National Policy Oral Health (PNSB, 2004). The approach of the policies proceeded up under the theory of M. Foucault\'s work on the Archaeology of Knowledge (1997). The study aimed to discover which operating knowledge, (Mendes Gonçalves 1979, 1994) has organized practice in this field. We used the review of regulatory documents and publications SUS from 2000 to 2012. We sought to reveal, from the technological organization (analysis category) as the current policy sees the health needs of the population and what tools / instruments / technologies are offered to oral health care. The SUS search has sought to change care models and work organizations that transform the practice of dental assisting (ineffective, low coverage, monopolistic, low resolution, poorly distributed geographically and socially), for models aimed at health promotion. However, according to a survey of articles about the conduction of current PNSB in the routine of public health services, said a modus operandi still supported in the pragmatic dentistry, full of conflicts and contradictions. The approach of concepts such as: health promotion, and integrality health care have brought a luminosity to this study, a clarity look at at the practice in oral health. The historic Policy Oral Health was fundamental to compose the analysis of technological organization and work processes, as highlighted that the guiding line of practices has been performed, linearly, by approaches still very centered on biological knowledge of the illness. For a really new model as proposed by the PNSB turn the practice of oral health with new technological arrangements in the work process, other forms of ties and compromise to be desired. It is necessary to improve training and professional practice by adding new knowledge which will require new cultural and cognitive standards. It must be qualify the listening about the sufferings of the patient, to go beyond of the diagnosis of signs and symptoms, to capture subjectivities produced in the condition of illness. Perhaps these processes are able to legitimize the oral health as a component of health in a larger expression: a quality of life.

O objeto da pesquisa foram as relações sociais estabelecidas entre o agente comunitário de saúde ACS e a equipe de Saúde da Família SF em situações concretas de trabalho. A SF é estratégia prioritária para a reorganização da Atenção Básica no Brasil. A profissão do ACS foi regulamentada somente em 2002 e caracteriza-se pelo exercício de atividades de prevenção de doenças e promoção da saúde. A literatura aponta que os ACS desempenham ações preconizadas pelo Ministério da Saúde, mas enfrentam dificuldades para cumprirem com funções de caráter mais político e social, voltadas para mudanças nos modos de se cuidar e para o aumento da participação social. O ACS possui características híbridas e singulares, pois é membro da comunidade e da equipe de saúde, propiciando a ligação entre esses dois atores. Objetivou-se compreender as relações sociais estabelecidas entre o ACS e a equipe de SF a partir do trabalho em equipe na saúde, destacando os aspectos da articulação das ações e da interação entre os trabalhadores. A pesquisa foi de abordagem qualitativa com a realização de 23 observações participantes e 11 entrevistas semi-estruturadas junto a uma equipe de SF em um município do interior paulista, O material empírico foi interpretado segundo a análise temática e compreendeu a história da unidade de saúde e seus trabalhadores, o processo de trabalho da equipe e os ACS na equipe de SF na perspectiva da articulação e da interação. Os resultados mostraram que o ACS está inserido em um processo de trabalho em equipe que é dinâmico. O ACS vive as contradições de modelos de saúde que são diferentes e co-existem em um mesmo espaço. Os ACS são laços de ligação quando desempenham ações articuladas ao trabalho da equipe e interagem com os trabalhadores, construindo planos assistenciais em comum. Um núcleo de competência do ACS pode ser a característica de laço de ligação, aproximando equipe e comunidade e adequando as ações de cuidado às reais necessidades das pessoas. Na prática comunicativa com os trabalhadores; os ACS ao falarem de si, estão falando da própria comunidade, pois é ele seu representante e porta-voz na equipe. Como elos de ligação desenvolvem ações essencialmente operacionais para agilizar o trabalho da equipe e da unidade, tais como, entregar recados e encaminhamentos. As atividades desempenhadas dentro da unidade relacionam-se à cooperação e também estão muito atreladas às ações operacionais e instrumentais do trabalho, inclusive com certo caráter de troca. Concluímos que a inserção do ACS na equipe de SF enfrenta dificuldades e requer a criação de estratégias que favoreçam a relação dialógica entre os trabalhadores. Assim, o trabalho da equipe e a dimensão política e social dos ACS poderão ser potencializados, contribuindo para cuidados mais integrais e acolhedores e para um agir em saúde mais criativo e prazeroso. / The social relations established between the community health agent (ACS) and the health family team (SF) in work situations was the object of this study. SF has been a strategic priority to reorganize Primary Health Care in Brazil. ACS only became a regulated profession in 2002 and comprises activities of disease prevention and health promotion. Literature appoints that ACS develops actions recommended by the Ministry of Health but faces difficulties in complying with functions with a more political and social character focused on changing peoples self-care and increasing their social participation. These professionals possess hybrid and singular characteristics because they are both members of the community and the health team making linkages between them. The study aimed to understand the social relations established between the ACS and SF team as from the work developed by the health team, highlighting connections between actions and interaction between workers. This is a qualitative study with 23 participant observations and 11 semistructured interviews with the SF team in a city in the interior of Sao Paulo, Brazil. The empirical material was analyzed according to the thematic analysis and comprises the history of the health unit and its workers, the teamwork process and the perspective of connection and interaction of the ACS in the SF team. Results revealed that ACS is inserted in a dynamic teamwork process, that is, experiences the contradictions of co-existing different health models. These professionals work as links when they develop actions connected to the teamwork and interact with its workers developing common care plans. The ACS core of competency is characterized by the connection they establish approximating team and community and adapting care actions to peoples real needs. When these professionals talk about themselves during communication with workers, they talk about the community itself because they are its representatives and spokesman in the team. As links, they basically develop operational actions to speed up the team and units work such as delivering messages and referrals. The activities developed inside the unit are related to cooperation and are also very associated to operational and instrumental work, which includes a certain exchange. The conclusion is that the inclusion of the ACS in the SF team is difficult and requires strategies favoring the dialogical relation between workers. This way, the teamwork and the ACS political and social dimensions can be strengthened, contributing to more integral and welcoming care and also to more creative and gratifying work in health.

Os serviços de Atenção Básica à Saúde (ABS) do Sistema Único de Saúde são responsáveis pela maioria dos atendimentos pré-natais no Brasil. O pré-natal alcançou elevada cobertura no país, contudo, atingir um número mínimo de consultas não garante a qualidade da atenção. Ademais, permanecem iniquidades no acesso ao cuidado pré-natal, sendo que, as regiões mais pobres possuem mais difícil acesso, persistindo desfechos maternos e perinatais negativos. O objetivo geral desse estudo foi avaliar o cuidado pré-natal nos serviços de ABS que participaram do segundo ciclo do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB) no estado do Piauí. Trata-se de uma pesquisa avaliativa do tipo análise da implantação, subtipos 1-a, 1-b e 3, de corte tranversal. Elaborou-se os modelos lógico teórico e operacional do cuidado pré-natal nos serviços de ABS. A população desse estudo consistiu em 865 equipes de ABS que participaram da avaliação externa no segundo ciclo do programa, 788 unidades de saúde e 235 mulheres grávidas ou com filhos até dois anos de idade que responderam um questionário na ocasião da avaliação externa. Utilizou-se dados secundários provenientes do banco de dados da avaliação externa do Ministério da Saúde, coletados de janeiro a setembro de 2014. Descreveu-se a estrutura das unidades de saúde, o processo de trabalho das equipes e o cuidado recebido durante o pré-natal pelas mulheres entrevistadas. Analisou-se a prevalência da adequação da estrutura e do processo de trabalho para o cuidado pré-natal segundo as macrorregiões administrativas do estado, Índice de Desenvolvimento Humano municipal (IDHm), porte populacional e atendimento à população rural. Somente 3,7% das unidades de saúde possuíam estrutura adequada para o cuidado pré-natal, sendo as menores frequências as dos testes rápidos de gravidez (10,3%), HIV (8,6%) e sífilis (7,4%). O processo de trabalho foi adequado para 20,8% das equipes e a menor frequência foi da administração de penicilina G benzatina nas unidades de saúde (55,0%). Das mulheres entrevistadas, 10,6% receberam todos os cuidados pré-natais selecionados. A macrorregião dos Cerrados se destacou quanto à adequação da estrutura para o cuidado pré-natal. Em relação à adequação dos equipamentos e materiais para a realização de procedimentos clínicos-obstétricos e suprimento de vacinas, as unidades de saúde dos municípios com maior IDHm são mais prevalentes. Considerando a adequação do processo de trabalho, as equipes da macrorregião do Semiárido são mais prevalentes e quando analisada a solicitação de exames, as equipes com maior IDHm e que não atendem população rural são mais prevalentes. Os resultados apontam que o maior desafio é ofertar todos os cuidados preconizados para o pré-natal, o que distancia a prática desses serviços de saúde da integralidade. Observa-se que, quando a prestação de um cuidado depende de maior infraestrutura, os serviços dos municípios de maior IDHm são mais prevalentes. São necessários esforços para incrementar a estrutura das unidades de saúde e estimular as equipes a explorarem mais as tecnologias leves no cuidado. Ressalta-se a premência em suprir as unidades com os testes rápidos e realizar a administração da penicilina G benzatina nas unidades de saúde / The services of Primary Health Care (PHC) of the Unifield Health System [Sistema Único de Saúde] are responsible for the majority of the prenatal care in Brazil. Prenatal care has reached high levels of coverage in the country; however, reaching a minimum of doctor\'s visits does not guarantee the quality of care. Moreover, inequalities in access to prenatal care remain, given that the poorest regions have the most difficult access to care, and adverse maternal and perinatal outcomes persist. The general aim of this study was to evaluate the prenatal care in the services of PHC providers that participated of the second cycle of the National Program to Improve Access and Quality of Primary Care [Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica - PMAQ-AB] in the state of Piauí. This consists of an evaluative research of the analysis of implementation type, subtypes 1-a, 1-b and 3, cross sectional study. The study elaborated the logical, theoretical, and operational models of prenatal care in the services of PHC. The population of this study consisted of 865 teams of PHC providers that participated of the external evaluation in the second cycle of the program, 788 healthcare facilities, and 235 pregnant women or women with children up to two years of age who answered a questionnaire when the external evaluation took place. The study used secondary data from the Ministry of Health\'s external evaluation, which was collected from January to September 2014. The study described the structure of the healthcare facilities, the teams\' work processes, and the care the interviewed women received during their prenatal care. The study analyzes the prevalence of the structure and the work process adjustment for prenatal care according to the macro administrative regions of the state, the, the municipal Index of Human Development (IHDm), population size, and services to the rural population. Only 3.7% of the healthcare facilities had the appropriate structure for prenatal care, the lowest frequencies were for rapid pregnancy tests (10.3%), HIV (8.6%), and syphilis testing (7.4%). The work process was appropriate in 20.8% of the teams and the lowest frequency was that of the administration of Penicillin G Benzathine in the healthcare facilities (55.0%). 10.6% of the women interviewed received all the selected prenatal care. The Cerrados macro-region stood out in terms of the structure for prenatal care. Concerning the suitability of the equipment and materials for the implementation of clinical-obstetrical procedures and vaccine supplies, the healthcare facilities of the municipalities with the highest IHDm prevail. Considering the suitability of the work process, the teams of the Semiárido macro-region prevail, and when the requests for tests is analyzed, the teams with the highest IHDm, and who do not serve rural populations, prevail. The results point out that the greatest challenge is to offer all recommended prenatal care, which distances the practice of these healthcare services from completeness. It can be observed that, when the care provision depends on greater infrastructure, the services of the municipalities with the highest IHDm prevail. There is a need for efforts to increase the structure of the healthcare facilities and to stimulate the teams to explore more soft technologies in care. The study emphasizes the urgency in supplying facilities with rapid tests, and carrying out the administration of Penicillin G Benzathine in the healthcare facilities

Submitted by Rosina Valeria Lanzellotti Mattiussi Teixeira (rosina.teixeira@unisantos.br) on 2015-04-30T12:12:17Z No. of bitstreams: 1 Bruno Vieira Cariry.pdf: 1014562 bytes, checksum: 695277f43d05386551478d66ceda3c29 (MD5) / Made available in DSpace on 2015-04-30T12:12:17Z (GMT). No. of bitstreams: 1 Bruno Vieira Cariry.pdf: 1014562 bytes, checksum: 695277f43d05386551478d66ceda3c29 (MD5) Previous issue date: 2013-12-05 / Introduction: The expansion of Family Health Estrategy in Brazil requires a construction of indicators that will evaluate the coherence of the approach effectively carried through and their guiding principles. The register in patient records is important for managers in health because it represents an indicator of quality in primary care. It can also work as an instrument of legal and ethical support for the professionals in charge of patient care, and helps in diagnosis and choosing of treatment. Objective: Evaluate the use of patient records by employees and managers of Primary Care in cities of hinterland of Paraiba state. Methodology: A semi-structured questionnaire with questions about biodemographic data and practical actions of healthcare professionals and managers towards the use of patient records was applied. Descriptive analysis was performed for all variables. Results: From analysis of the questionnaires, seven thematic categories that reflects the position of the group on the use of health records and their variables emerged: the need for a computerized system; incentive for use of records and information system; insatisfaction with manual registers; lack of knowledge of information systems; desire to classify all phases of care; uncertainty with regard to computerized system; and devaluation of records in Health. Conclusion: Managers and professionals must understand the importance of the use of patient records, in all their forms of presentation, for the process of health assistance managing as well as they should develop the stimuli in themselves and in their colleagues to make correct use of this instrument. / Introdução: A expansão da Estratégia de Saúde da Família no Brasil torna necessária a construção de indicadores que avaliem a coerência da abordagem efetivamente realizada e os seus princípios orientadores. O registro em prontuário é importante para os gestores em saúde, pois representa um indicador de qualidade da atenção básica. Também pode se constituir em instrumento para respaldo ético e legal aos profissionais responsáveis pelo cuidado ao paciente, bem como auxiliar na construção de diagnósticos e escolha de tratamentos empregados. Objetivo: Avaliar o uso de prontuários pelos profissionais e gestores da Atenção Básica em municípios do sertão paraibano. Metodologia: Foi aplicado entre os participantes um questionário semiestruturado com perguntas sobre dados biodemográficos e questões relacionadas a atitudes práticas do profissional de saúde ou gestor frente à utilização do prontuário. Foi realizada a análise descritiva de todas as variáveis. Resultados: Emergiram da análise sete temáticas de discussão que refletem o posicionamento dos grupos pesquisados sobre o uso de registros e saúde e suas variáveis: necessidade de sistema informatizado, incentivo para o uso do prontuário e sistema informatizado; insatisfação com o registro manual; pouco conhecimento sobre sistemas de informação; desejo de classificar todas as fases do atendimento, insegurança quanto ao sistema informatizado; e desvalorização dos registros em saúde. Conclusão: Gestores e profissionais devem compreender a importância de uso do prontuário, nas suas mais diferentes formas de apresentação, para o processo de gestão da assistência na saúde, bem como devem desenvolver estímulo em si mesmos e nos seus colegas para a correta utilização desse instrumento.

Transitional care is an important process for professionals to consider, particularly as recent studies have shown how a mental health difficulty in adolescence will persist into adulthood. This indicates that a number of those seen in Child and Adolescent mental health services are likely to make the transition into Adult services. For professionals from both services, barriers can arise when supporting young people across service boundaries and recent studies have stated that the current practice of transitional care in mental health is deemed to be problematic. However at the time of conducting this study, there was a paucity of literature, therefore the aim of the study was to add to the existing knowledge. The study followed a Social Constructivist grounded theory (Charmaz, 2014) approach to explore the experience of stakeholders of the transition process. Semi-structured interviews were conducted with professionals, young people and parents. There were a total of eight interviews which were transcribed and analysed. The findings present the core category as Facing the transition, with three sub- categories: Changing status, Manoeuvring the boundaries and Reflections on the process. The tentative theory explains how facing the transition involves stakeholders adjusting to the changing status of the service user. This category triggers the service transition but also describes how societal perceptions about adulthood influence the expectations placed on young people. Manoeuvring the boundaries describes and explains service transition, identifying a range of barriers and strategies to overcome these. One of the most significant barriers was identified as cultural differences between the two services. The third category describes how stakeholders make sense of their experiences, and how these are managed within the therapeutic relationship.

Background The World Health Organization (WHO) defines health as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. Despite its importance, mental health provisions are often limited. In 2015, Indonesia had only 773 psychiatrists for 250 million residents. This shortage of specialist mental health professionals is shared by most Low- and Middle-Income Countries (LMICs) and is reflected in the Treatment Gaps in this region indicating the very small proportion of people who receive adequate mental health care for their needs. While the median worldwide Treatment Gap for psychosis is 32.2% (Kohn et al., 2004), in Indonesia it is more than 90%. Experts suggested integrating mental health care into primary care, to help bridge this gap (Mendenhall et al., 2014). The systematic introduction of the World Health Organization Mental Health Gap Action Programme into primary care clinics across Indonesia and the presence of a 15-year-old co-location of Clinical Psychologists in Yogyakarta province's primary care clinics presented an opportunity to assess the clinical and cost-effectiveness of both frameworks. Methods This research ("the trial") set out to develop an approach, and then implement it, to compare the adapted WHO mhGAP framework with the existing specialist framework within primary mental health services in Yogyakarta, Indonesia, through a pragmatic, two-arm cluster randomised controlled non-inferiority trial. This design enabled an examination of patients derived from whole populations in a 'real world' setting. The trial involved two phases: a pilot study in June 2016 with the objectives to refine data collection procedures and to serve as a practice run for clinicians involved in the trial; as well as a substantive trial beginning in December 2016. The 12-item General Health Questionnaire (GHQ-12) was established as a 'fairly accurate' screening tool using a Receiver Operating Curve study. Using the GHQ scoring method of 0-0-1-1, a threshold of 1/2 was identified for use in clinical setting, i.e. the context of the trial. The primary outcome was the health and social functioning of participants as measured by the Health of the Nation Outcome Scale (HoNOS) and secondary outcomes were disability as measured by WHO Disability Assessment Schedule 2.0 (WHODAS 2.0), quality of life as measured by European Quality of Life Scale (EQ‐5D-3L), and cost of intervention evaluated from a health services perspective, which aimed to determine the clinical effectiveness and cost-effectiveness of both frameworks at six months. Results During the recruitment period, 4944 adult primary care patients attended 27 participating primary care centres. Following screening (n=1484) and in-depth psychiatric interviews (n=394), 174 WHO mhGAP arm and 151 Specialist arm participants received a formal diagnosis and were recruited into the trial. The number of required participants per treatment arm, to provide statistical power of 0.80 and statistical bilateral significance value of 0.05 was estimated to be 96. A total of 153 participants of the WHO mhGAP arm and 141 of the Specialist arm were followed-up at six months, representing 90.8% of all participants diagnosed. At follow-up, 82% (n=126) participants of the WHO mhGAP arm indicated they had attended at least one treatment session during the trial, significantly more than in the Specialist Arm (69%; n=97), 2 = 7.364, p=0.007. The WHO mhGAP arm was proven to be statistically not inferior to the Specialist arm in reducing symptoms of social and physical impairment, reducing disability, and improving health-related quality of life at six months. Cost-effectiveness analyses show that the Specialist arm was dominant for a unit of improvement in patient outcomes at six months. While the framework is more expensive for the Health System, participants in the Specialist arm were found to have larger improvements. Conclusion Given that both frameworks yielded positive patient outcomes, there is no immediate need to increase the absolute number of specialist mental health professionals in community psychiatry (i.e. replicate the specialist framework outside Yogyakarta). As most psychologists and psychiatrists in Indonesia reside in large cities, the current systematic roll-out of the adapted WHO mhGAP framework might address the need to strengthen non-stigmatising mental health care within community contexts, reflecting the preferences of primary care patients. In districts or provinces which could afford the additional cost, however, the Specialist framework was shown to be better at improving patient outcomes than the adapted WHO mhGAP framework. Existing resources for specialist care can be arranged in a hub-and-spoke (step-up care) model where higher-level interventions are provided for those with greater needs. The proposed model would free-up resources for advanced clinical training of the specialist workforce in key areas of need while keeping specialist services accessible. Trial Registration This trial has been registered with clinicaltrials.gov since 25 February 2016, NCT02700490. Ehical Standards Full ethics approval from the University of Cambridge, UK was received on 15 December 2015 (PRE.2015.108) and from Universitas Gadjah Mada, Indonesia on 14 April 2016 (1237/SD/PL.03.07/IV/2016). A condition of ethics approval from the University of Cambridge is that the investigator is covered by indemnity insurance and that participants are insured for the period of their participation. This was provided by the University of Cambridge Trial Insurance Office (609/M/C/1510). Ethics approval from all the clusters was not required as each cluster (Puskesmas) is a local GP surgery which does not have its own ethics committee. Instead, approval to conduct research at the province of Yogyakarta including all five districts: Kota Yogyakarta, Sleman, Gunung Kidul, Kulon Progo, Bantul Districts was obtained from the Provincial Government Office (070/REG/V/625/5/2016) following ethics approvals. Written consent to participate was obtained from clinicians taking part as well as all patient-participants.